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APPLICATION INSTRUCTIONS (North Hennepin Community College)

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Qualified Applicants
Only High School Juniors and Seniors are eligible for admission consideration through this PSEO admission process. Students
admitted through this program will qualify for enrollment in both general education courses and career and technical courses.
Application Deadlines
Deadlines will be adjusted to the next business day if the date below falls on a weekend. Any applications or supplemental
documents received after the deadline will not be considered.
Fall Semester
Spring Semester
Priority Deadline - April 15
th
Priority Deadline – November 1
st
Final Deadline – July 1
st
Final Deadline – December 1
st
PSEO Requirements to Qualify for Accuplacer Test Eligibility
High School Juniors:
High School Seniors:
Rank in the top one-third (66%) of their graduating class
Rank in the top one-half (50%) of their graduating class
OR
OR
Place into the top 1/3 on a nationally standardized test
Place into the top 1/2 on a nationally standardized test
PSEO Application Checklist:
NHCC PSEO Application (PSEO students do not pay an application fee)
MN Department of Education Notice of Student Registration (MN State form) with signatures from
student, parent/guardian and high school official.
Official High School Transcripts (in a sealed envelope from the school). Transcripts must include the
most recent semester grades.
Official standardized test scores are also required if you attend homeschool, charter or alternative schools,
and if no class rank is indicated on your official transcript. Examples of accepted tests include, but are not
limited to ACT, SAT and PLAN. Test results must be no more than 12 months old at the time of submission.
Test results indicated on an official high school transcript are acceptable only if national rank is included.
Take the Accuplacer Test to determine if admission into the PSEO program will be granted. Admission
will be granted only to students testing at college level on the reading portion of the test. Test waivers will be
considered upon request to the NHCC Testing Center. See
www.nhcc.edu/testing for additional information.
STEP 1: Complete and submit ALL application documents together
Before submitting your application, make sure you have included all of the required documents listed below.
Incomplete applications will result in a delay of processing for determination of PSEO eligibility and next steps.
STEP 2: Schedule Accuplacer Testing after you receive a notification letter in the mail
indicating that you are eligible to test.
Schedule your testing appointment well in advance. Testing must be completed prior to the PSEO application
deadline. Students are responsible for submitting NHCC test results (or approved test waiver) to Admissions.
Post-Secondary Enrollment Options (PSEO)
APPLICATION INSTRUCTIONS
General College Eligibility
Updated 06/12/2014
Date ____________________________ Social Security Number ______________________________________ (optional)
Providing your Social Security number is voluntary. If you choose not to provide the number, your application will still be processed. Providing your Social Security number is required if you are seeking financial aid, veteran’s benefits or if you plan to deduct
your educational expenses from your federal taxes. Your Social Security number is also used as your initial personal identification number (PIN) for various computer resources such as class registration. Failure to provide your Social Security number may
prevent you from having access to these resources. The number is also requested for purposes of administration, program evaluation, and consumer and alumni data.
PERSONAL DATA (Please print)
First Name ____________________________ Last Name _______________________________ Middle Name ________________
Address ________________________________________ City ___________________________ State _______ Zip ____________
Email Address _______________________________ Home Phone ____________________ Cell Phone __________________
Date of Birth (month/day/4-digit year) ____________________
Are you a resident of MN?
□ Yes □ No If yes, how long? ____ years ____ months
If no, state of residence ________ (
If you are not a resident of MN, you are unable to participate in the PSEO program)
Are you a US Citizen?
□ Yes □ No
If no, do you have a status as: ___ Resident Alien ___ Refugee/asylee ___ Temporary protected status ___ Other: ________________
ADMISSIONS DATA
What term do you intend to begin taking courses: □ Fall □ Spring Year ____________
Major: □ Liberal Arts / General Studies □ Other (Be Specific): _________________________________________________
Do you plan to attend:
□ Full time □ Part time
What is your current educational intent?
____Complete courses, no degree ____ Earn occupational certificate/diploma ____ Earn Associates degree
____ Earn Associates degree and transfer ____ Complete courses and transfer without degree
Have you attended this college before:
□ Yes □ No If yes, last date of attendance: ___________________
EDUCATIONAL DATA
High School (current) ___________________________________________City _____________________________ State __________
Graduation month /year ______________________ Have you attended any college or university previously?
□ Yes □ No
List all colleges/universities previously attended below. Have these official transcripts sent to NHCC.
NAME OF INSTITUTION
LAST DATE OF ATTENDANCE
Application Continued on Back Page
Post-Secondary Enrollment Options (PSEO)
APPLICATION INSTRUCTIONS
General College Eligibility
Updated 06/12/2014
The following will help Minnesota State Colleges and Universities evaluate student recruitment and retention policies; it will not be used as a
basis for admission. Providing this information is voluntary.
Gender:
□ Female □ Male
Are you Hispanic or Latino? □ Yes □ No
(A person of Cuban, Mexican, Chicano, Puerto Rican, South or Central American or other Spanish culture, regardless of race)
Race and ethnic background - Please select all that apply:
___ American Indian or Alaska Native
(A person having origins in any of the original peoples of North, Central or South America and who maintains tribal
affiliation or community attachment)
___ Asian (A person having origins in any of the original peoples of the Far East, Southeast Asia or the Indian subcontinent)
___ Black or African American
(A person having origins in any of the black racial groups of Africa)
___ Native Hawaiian or Pacific Islander
(A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands)
___ White
(A person having origins in any of the ordinal peoples of Europe, the Middle East or North Africa)
___ Two or More Races
CONFIDENTIAL INFORMATION
Supplemental Documents
By initialing each item below, I verify that all required materials listed below have been are being submitted along with my application.
_____ MN Department of Education Notice of Student Registration with signatures from student, parent/guardian and high school official.
(Initials)
_____ Official High School Transcripts (in a sealed envelope from the school). Transcripts must include the most recent semester grades.
(Initials)
_____ Official standardized test scores are also required if you attend homeschool, charter or alternative schools, and if no class rank is
(Initials) indicated on your official transcript. Examples of accepted tests include, but are not limited to ACT, SAT and PLAN. Test results
must be no more than 12 months old at the time of submission. Test results indicated on an official high school transcript are acceptable
only if national rank is included.
_____ NHCC PSEO Agreement of Understanding found at www.nhcc.edu/pseo has been thoroughly reviewed (does not need to be
(Initials) submitted to NHCC).
Signature
In signing this application, I certify that the information I have provided on this application form and in all other admission application materials
is complete, accurate and true to the best of my knowledge. I also certify that I have thoroughly reviewed and agree to all of the terms listed on
the PSEO Agreement of Understanding.
Applicant’s Signature: ____________________________________________________________ Date: __________________________
Access to Student Records
Required The college will not permit access to or the release of personally identifiable information contained in student educational records without the written consent of the student to any third party, except as
authorized by the MGDPA and FERPA or other applicable law. A copy of the Release of Private Educational Data form is available in Student Services offices, academic areas, and the college Information Drive. A
written consent is valid if it: 1) specifies the records that may be disclosed; 2) states the purpose of the disclosure; 3) identifies the person(s) to whom the disclosure may be made; and 4) is signed and dated by the
student. If the release is for disclosure to an insurer or its representative, the release must also include an expiration date no later than one year from the original authorization, or two years for a life insurance
application. If the student requests, the school shall provide him or her with a copy of the records released pursuant to the informed consent.
NHCC is a member of the Minnesota State Colleges and Universities System and an Equal Opportunity Educator and Employer.
For disability accommodations call 763-493-0555. Minnesota Relay users may call 1-800-627-3529.
Updated 06/12/2014
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POSTSECONDAR Y ENROLLME N T OPTIONS P ROGRA M
NOTICE OF STUD E N T REGISTRATION
ED-01763-15
NOTE: Complete a separate form for each instructional term, AND for each postsecondary institution attending. Please print and
use black ink. ALL BOXES MUST BE COMPLETED. This form must be mailed to the Post-Secondary Institution you choose to
attend. Students should not mail this application to MDE.
School Year: 2015-16 College Student ID Number:
1.
TO BE COMPLETED BY THE STUDENT
Student Name (Last, First, M.I.): Circle one
M
F Date of Birth (MM/DD/YYYY):
Address: City:
Zip Code:
Student Email: Telephone Number:
Parent/Guardian Name: Address (if different than above):
Postsecondary institution you plan to attend this term: North Hennepin Community College
Minnesota
Statutes, section 124D.09, requires that students and parent/guardians sign a statement indicating they have received information
about the program, are aware that counseling services are available and understand the responsibilities regarding enrollment in postsecondary
courses. We have received the information required under Minnesota Statutes, section 124D.09, and are aware the above student is enrolling in
postsecondary courses.
Signature – Parent/Guardian (if student is under 18) Signature – Student Date
Directions: Upon completion of Section 1, please pass this form to the pupil’s secondary school for completion of Section 2.
2.
TO BE COMPLETED BY THE SECONDARY/NON-PUBLIC/HOME SCHOOL
Name of Secondary/Non-Public/Home School Attending: School Classification (Circle one only):
Public Non-public
Home
13 Digit MARSS Student Number (public student only):
Name of School District of Attendance: Attendance District Number and Type:
Resident District: Resident District Number and Type:
Is the above student eligible for program application? (see page 3 for requirements)(Circle one)
YES
NO
IF NOT ELIGIBLE, RETURN FORM TO STUDENT,
DO NOT CONTINUE PROCESSING.
During period of attendance at postsecondary institution student’s secondary grade level will be: (Circle Grade)
Grade 10 *Public Students Only
Grade 11 Grade 12
NOTE: HIGH SCHOOL GRADUATES AND 21 YEAR-OLDS ARE NOT ELIGIBLE
Student may not enroll in PSEO in addition to a full high school course load. Does the student
have at least one free class period during the school day? (Circle One) YES NO
SECONDARY/NON-PUBLIC /HOME SCHOOL VERIFICATION
I certify that the student identified in section 1 meets the eligibility requirements outlined in Minnesota Statutes, section 124D.09, to apply for
participation in the Postsecondary Enrollment Options (PSEO) program this term, and that the information in section 2 is accurate and applicable to
the student..
Signature – Secondary School Contact Person
Title
Date
Secondary School Contact Name Typed or Printed Telephone Number Email Address
Directions: Upon completion of Section 2, please pass this form to the postsecondary institution for completion of Section 3.
POSTSECONDARY ENROLLMENT OPTIONS PROGRAM NOTICE OF STUDENT REGISTRATION ED-01763-15
Page 2
3. TO BE COMPLETED BY THE POSTSECONDARY INSTITUTION
Name of Postsecondary Institution: City of Postsecondary Institution:
North Hennepin Community College Brooklyn Park
College Student ID Number: Term of Planned Attendance (Circle one only):
Qtr 1 Qtr 2 Qtr 3 Sem 1 Sem2
Postsecondary Institution Contact Person: Title:
Melissa Leimbek Director of Records & Registration
Telephone Number: 763-424-0719 E-Mail Address: registration@nhcc.edu
COURSES TAKEN FOR SECONDARY CREDIT OR DEVELOPMENTAL EDUCATION COURSE NUMBER COURSE CREDITS
1. 1.
POSTSECONDARY REGISTRATION VERIFICATION
I certify the student identified in section 1 is registered this term for the courses indicated, all courses are non-sectarian in content, are not
remedial or developmental, and that the student has indicated to me the courses are to be taken for secondary credit.
Signature – Postsecondary Institution Contact Person Date
2.
2.
2.
3.
3.
3.
4.
4.
4.
5.
5.
5.
6.
6.
6.
Direction: Within 10 days following completion of section 3, the postsecondary institution must mail a LEGIBLE copy of this
form to the following address: Minnesota Department of Education, Division of School Finance, 1500 Highway 36 West,
Roseville, MN, 55113. Additionally, copies of the completed form must be sent to the student indicated in section 1 and the
secondary school of attendance indicated in section 2.
Student Name (Last, First, M.I.):
Date of Birth (MM/DD/YYYY):
POSTSECONDARY ENROLLMENT OPTIONS PROGRAM NOTICE OF STUDENT REGISTRATION ED-01763-15
Page 3
POSTSECONDARY ENROLLMENT OPTIONS PROGRAM
STUDENT ELIGIBILITY - Refer to Minnesota Statutes, section 124D.68, and section 124D.09
Any pupil in a Minnesota public, nonpublic, home school or American Indian-controlled tribal contract or grant school eligible
for aid under section 124D.83, except a foreign exchange pupil enrolled in a district under a cultural exchange program,
classified as an 11th or 12th grader and accepted by a postsecondary institution, may enroll either full- or part-time in
nonsectarian courses at an eligible postsecondary institution. Eligible 10
th
grade students may enroll in a Career and Technical
Education (CTE) course offered by a Minnesota state college or university. Please review requirements below.
A.
A student must be enrolled in school in the 11
th
or 12
th
grade;
OR
A student who is in the 10
th
grade may apply to an eligible postsecondary institution for the purpose of enrolling in a Career
and Technical Education (CTE) course. The 10
th
grade student must have taken the 8
th
grade MCA reading test in the 8
th
grade
and have met the composite proficiency level of meets or exceeds.
B.
Limit on Participation:
1)
A pupil who first enrolls in grade 9 may not enroll in postsecondary courses for more than the equivalent of four
academic years.
2)
A pupil who first enrolls in grade 10 may not enroll in postsecondary courses for more than the equivalent of two
academic years.
3)
A pupil who first enrolls in grade 11 may not enroll in postsecondary courses for more than the equivalent of two
academic years , except for state approved Learning Year Programs pursuant to Minnesota Statutes, section
124D.128, summer sessions are not included.
4)
A pupil who first enrolls in grade 12 may not enroll in postsecondary courses for more than the equivalent of one
academic year.
5)
If a pupil in grade 9, 10, 11, or 12 first enrolls in a postsecondary course for secondary credit during the school year,
the time of participation shall be reduced proportionately.
C.
For purposes of determining PSEO eligibility:
1)
An academic year is equivalent to a school year. A school year is defined as July 1 through June 30.
2)
If a pupil is in a learning year or other year-round program and begins each grade in the summer session, summer
sessions shall not be counted against the time of participation.
3)
A pupil who has graduated from high school cannot participate in a PSEO program.
4)
A pupil who has completed course requirements for graduation but who has not received a diploma may participate
in the program.
D.
If a student first enters the program during the academic year, the time of participation is reduced proportionally.
E.
If a student withdrew from high school for medical or other unavoidable reasons, prior to the beginning of the
postsecondary institution’s 2
nd
semester, and generated no general education revenue through the remainder of the
school year after withdrawal, the student would be eligible to extend eligibility by one semester.
F.
An institution shall not enroll secondary pupils, for postsecondary enrollment options purposes, in sectarian, remedial,
developmental, or other courses that are not college level unless the student is an alternative education student
participating in an approved full-time early/middle college program designed to earn a certificate or degree.
G.
In 2003, the PSEO law was amended so that the books are now returned to the college not the high school. Minnesota
Statute, section 124D.09, Subdivision 20 (2002), is amended to read: “Subdivision 20, TEXTBOOKS; MATERIALS. All
textbooks and equipment provided to a pupil, and paid for under subdivision 13, are the property of the pupil’s
postsecondary institution. Each pupil is required to return all textbooks and equipment to the postsecondary institution
after the course has ended.”
For more detailed information on the program and its requirements, please view the Postsecondary Enrollment Options
School Finance page MDE > School Support > School Finance > Postsecondary Enrollment Options on the Minnesota
Department of Education’s website.
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APPLICATION INSTRUCTIONS (North Hennepin Community College)

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